Introduction

The controversy over drug policies reached a new height last summer at the 2010 International AIDS Conference, held in Vienna, Austria. For decades, most countries have criminalized illicit drug use while many healthcare professionals, researchers and community members have advocated a harm reduction approach, one that minimizes the harmful consequences of illicit drug use. The AIDS 2010 Conference marked the launch of the Vienna Declaration, which calls for a full re-orientation of drug policies. The Vienna Declaration points to the failure of the international "War on Drugs" to achieve its stated objectives and calls for drug policies based on scientific evidence. So, what does the evidence tell us about the links between illicit drug use and the prevention of HIV? What does it tell us about the effectiveness of drug prohibition vs. harm reduction?

More About the Vienna Declaration

Who Has Signed It?

As of January 2011, the Vienna Declaration had been signed by close to 19,000 individuals, organizations and governments. These include leaders in science and medicine, heads of state, Nobel Laureates, academic institutions and municipal governments, as well as hundreds of human rights, public health, law enforcement, religious and civil society organizations.

Who Wrote It?

The Declaration was written by a team of 31 international experts, including six Canadians.

What Does It Say?

The criminalization of illicit drug users is fuelling the HIV epidemic and has resulted in overwhelmingly negative health and social consequences. A full policy reorientation is needed...

Coinciding with the release of the Vienna Declaration, The Lancet -- one of the top scientific journals in the world -- published an issue on "HIV in people who use drugs." In a series of articles, scientists describe the extent of the global health problems associated with injection drug use and present the most recent evidence about effective interventions. We summarize some of the key issues addressed in these articles. When you get a chance, read the articles!

The Backdrop

As of 2007, an estimated 15.9 million people around the world injected drugs and approximately 18% of injection drug users were infected with HIV.

In some parts of the world, such as Eastern Europe and Central Asia, 70% to 85% of injection drug users are HIV-positive.

Outside of sub-Saharan Africa, injection drug use accounts for approximately one in three new cases of HIV.1

Using a combination of strategies (including sterile needles or syringes, opioid substitution treatment and antiretroviral medications, among others) and treating illicit drug use as a public health issue rather than a criminal justice issue could significantly reduce the risks of HIV infection.

What Do We Mean by "Harm Reduction"?

Harm reduction refers to a philosophy and set of practices aimed at minimizing the potentially harmful consequences of drug use -- such as overdose and the transmission of HIV and hepatitis C -- and keeping people as healthy as possible.

Comprehensive HIV Prevention Programs Can Reduce HIV Transmission

Front-line workers know, and Louisa Degenhardt and her colleagues concur in one of the Lancet articles, that a combination of strategies is needed to effectively prevent HIV transmission among injection drug users and that those strategies need to reach as many people as possible.2 The long list of strategies include HIV testing and counselling, counselling to reduce the risk behaviours of individuals and couples, peers promoting changes in risk behaviours among their social networks, needle exchange programs, condom distribution, opioid substitution therapy, cognitive behavioural therapy, treatment of sexually transmitted infections (STIs) and antiretroviral treatment. Current evidence shows that each of these interventions reduces the number of injections, the riskiness of injection, sexual risk behaviours and/or the infectiousness of people living with HIV. Three of these interventions have proven to be especially beneficial -- namely, opioid substitution treatment, needle and syringe programs and antiretroviral treatment (for HIV-positive people with CD4 counts lower than 350 cells).

More Information on These Three Interventions

Opioid substitution treatment: Opioid substitution treatmentis the medical use of methadone or buprenorphine as drug replacement therapy for people who use opiates. These replacement opioids prevent withdrawal symptoms but do not produce the "high" associated with the use of opiates. Opioid substitution therapy has consistently been shown to reduce opiate use, crime and HIV risk behaviours.3-8 Higher doses, longer treatments and programs with support services all contribute to better outcomes.

Needle and syringe exchange programs: Needle and syringe exchange programs, which provide clean needles and syringes to injection drug users, reduce needle sharing. A systematic review of the literature found there is strong evidence that needle and syringe exchange programs reduce HIV risk behaviours and HIV infection in injection drug users.9 Another review, conducted by the World Health Organization (WHO), concluded that there is compelling evidence that if the availability and use of needle and syringe exchange programs increase, the HIV infection rate will be substantially reduced. The WHO also concluded that there was no evidence of any major negative consequences, that these programs are cost-effective and that they have additional benefits in addition to reducing HIV infection.10

Moreover, studies have shown that when a combination of these three interventions are provided to as many injection drug users as possible, HIV transmission may be reduced by more than 50%. For us to see this kind of impact, these programs must be readily available and accessible to as many drug users as possible.

Although providing drug users with opioid substitution treatment, clean needles and syringes, and antiretroviral treatment can cut HIV transmission in half, it is estimated that worldwide only 5% of drug injections involve a sterile needle or syringe; 8% of injection drug users have access to opioid substitution treatment; and 4% of HIV-positive injection drug users take antiretroviral medications.

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